The Struggle Is Real, The Solution Is Local

All healthcare is local. That trite, but true, aphorism is no less typified than when considering the trials and tribulations wrapped around the United States’ rural health clinics (RHCs) and providers. Though not necessarily a biproduct of the current economic climate, rural care delivery is impacted by a multitude of local factors; for instance, worker shortages exacerbated by the Covid burnout and higher paying jobs just down the road (e.g., 30 – 40 miles away). Whether it’s a clinic with rural status affiliated with a larger health system or academic medical center or a small critical access hospital coupled with smaller outpatient rural clinics, the challenges peculiar to rural healthcare delivery remain. Many rural health clinics, whether an hour from a major urban area or three hours away, have the same underlying structural issues as clinics in major metro areas but with a rural twist.

That said, even in the current undulating climate including emergence from Covid coupled with the international dynamic in eastern Europe, items can be addressed and solutions tailored to assist rural providers and health systems in sustaining care offerings for their communities coupled with financial viability and the ability to provide services to underserved populations.

What it Takes (in very broad strokes/generalizations)

What does it take to improve financial stability in a rural setting? As noted, one size never fits all. But the component pieces delineated below can go a long way toward reaching, or at least striving for, financial nirvana.

Providers – Before management suggests “our providers aren’t seeing enough patients,” impediments to care delivery must be mitigated to ensure providers are empowered to see patients efficiently and provide the necessary care to the community. Providers should have a de minimis production expectation. I’m not suggesting providers are widget makers and/or cogs in the machine. However, I am stating that there should be some form of production expectation to ensure that the provider coterie is meeting the community needs.

Whether it’s lifestyle, family roots, a desire to “give back,” forgiveness of student loan commitments, or an amalgamation of these factors, some providers prefer the rural lifestyle vs. the bustle of big city urban life. There are providers who relish the pace of rural medicine. While this is true and the pace suits them, providers should be removed from (complete) control of scheduling templates and dictates about visits. While this may be somewhat distasteful to the gentle reader, it is essential for the financial strength of the clinic. Blocking off an hour per day for “work ins” or charting is simply inefficient.

Visit Expectations/Schedules – Apropos of the above paragraph, a 6 – 8 patient per day caseload is simply not financially feasible nor, candidly, overly onerous on providers. (While not a clinician, after 32 years in the healthcare delivery space across the U.S., I feel at least nominally qualified to opine on this topic.) Providers should have schedules that accommodate local needs but are not overly “relaxed” allowing for an inordinate amount of block time, charting time, or multiple procedures during a normal office visit. Schedules should be crafted to offer patient access optimizing staff and scope of care to get patients into clinics. Specialty services, such as lesion removal, might best be considered for an add on clinic or a half day of clinic time where those specific needs can be scheduled and managed efficiently. (Later in this article I’ll contemplate the benefits of a minor expansion in schedules.)

Staffing – Yup, staffing across the country is difficult right now for a variety of reasons. While one hopes that wage inflation subsides, one might argue that recruiting for a rural health clinic is no more difficult than recruiting for an urban location (a colleague mentioned that a local urban health system currently has 4,000 job openings; yes, 4,000!)

While there is no pat answer for staffing challenges, some avenues are not dissimilar to meeting provider needs/wants. Clinics should endeavor to recruit local talent with aptitude and identify those who are invested in their personal growth while providing tools for upward mobility and opportunity. You might not keep them forever but with any luck you can grow them and move them up in the organization maintaining both talent and institutional knowledge.

Staffing, maybe now more than ever, requires active staff management and investment of time but the rewards can be generous. In today’s climate, will Suzy or Jimmy drive 40 miles each way for an extra dollar per hour when gas is $4.50 per gallon? I’m not sure. Providing a good opportunity with good compensation and rewarding work can go a long way to minimizing staff turnover.

Fee Schedules/Reimbursement – Though RHCs are not reimbursed like your typical fee-for-service clinic, there can be room to breathe with fee schedule and reimbursement review and assessment. RHCs should examine whether or not their charges are sufficient to satisfy not only reimbursement relative to the all-inclusive rate (AIR) but relative to their commercial payers.

Information Technology – If you are in a rural setting chances are your electronic medical record (EMR) is “killing” your providers. Whether that’s true, a crutch, or a mixture of both, perception is reality. I have seen rural groups that profess to have a robust EMR only to learn that there still exist manual processes (and work arounds) that consume both staff time and unnecessarily increase provider touches. These processes can include referrals and labs that should otherwise be exchanged electronically.

In some instances, RHCs don’t have the IT bandwidth or local interest to substantiate an aggressive telehealth solution. However, where possible, telehealth applications can aid in patient access and provide needed care management for those patients battling chronic conditions thereby, in theory, reducing unnecessary visits in the clinic.

Simple Math

Increasing patient-facing time is essential to meeting financial demands. In my overly simplified math, I’m removing Medicare’s AIR and crafting a somewhat absurd math exercise. The example below, while not precise and/or “real,” is directionally appropriate and considers patient volumes purely as commercial patients with fee allowables at 125% of Medicare’s current reimbursement rate. With the variables of improved patient flow, appropriate staffing, IT empowerment, and provider production we can see how these improvements impact revenues.

In Figure 1 below we consider a single provider, Dr. Schmoe. Dr. Schmoe works 226 days a year (five weeks off for vacation and CME, weekends, etc.) with, currently, a meager 2 new patients (call them 99203s) and 6 established patients (think 99213) per day. With visit impediments such as too few staff, EMR issues, and unnecessary schedule “blocks,” this may be all that Dr. Schmoe can manage during a given day.

Figure 1

In Figure 1 we note that Dr. Schmoe generated about $220,000 for the year. Depending on the type of provider (physician, PA, NP), this is not overly productive (approximately 2486 work relative value units [wRVUs]). Not only does that productivity not cover the cost of the provider salary, it does nothing to contribute to general overhead. In other words, our RHC is losing money daily simply by opening its doors.

Now, consider we’ve remedied many of the impediments to care delivery and we are able to get Dr. Schmoe 3 extra 99213s per day. (All aforementioned assumptions apply.) In Figure 2 our revenue increased nearly 35%. Understand, the goal of this exercise is not to level an argument for volume over value. Instead, it contemplates how nominal visit gains can positively impact the financial standing of the RHC while improving access to the members of the community. Additionally, although the 35% growth in visit volume, revenue, and wRVUs seems unattainable, the reality is that, in real numbers, both the visit volume (roughly 11 patients per day) and wRVU volumes are exceedingly low relative to peer groups. (This wRVU productivity is between the 35th – 45th percentile.)

Figure 2

Regardless of dictates from Washington D.C., healthcare will always be a local issue. There is no more a one size fits all solution to the financial ailments of RHCs than there is for a medical clinic in downtown Atlanta. Instead, actions must include an acute understanding of the local market and all of the variables from the cost and revenue sides of the ledger to divine the correct local balance between clinic resources, local demographics, and high-quality care delivery. What might fit in rural Iowa may not fit in rural Vermont so solutions must be tailored to the market, balanced, and constantly tended to ensure the rural garden continues to flourish.

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